Turning Heart Failure Into Heart Success: Transitioning CHF Patients to Home

Under CMS' Readmission Reduction Program, which took effect Oct. 1, hospitals will lose Medicare funds for excessive preventable readmissions of patients with acute myocardial infarction, heart failure or pneumonia. To avoid financial penalties and improve care for patients, many hospitals are targeting these diseases with new processes and interventions.

Dr. Sanjeev Gulati describes a transition program for heart failure patients.In January, Charlotte, N.C.-based Carolinas Healthcare System began a pilot program to improve care for congestive heart failure patients. Preliminary results have shown that the program, called Heart Success, has reduced readmission rates and improved the quality of care.

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Brainstorming healthcare solutions
One of the ways CHS aimed to improve heart failure care was by standardizing processes across the system. "We felt being able to improve and reduce variability of care would lead to downstream improvement such as a reduction of readmission rate and an increase in satisfaction and quality of life," says Sanjeev Gulati, MD, medical director of advanced heart failure at CHS' Sanger Heart & Vascular Institute, which includes Heart Success. "It led us to relook at how heart failure was managed."

To develop a standardized protocol for heart failure patients, a multidisciplinary group of senior administrators, cardiologists, family practitioners, IT employees, nurses and other stakeholders held several meetings to discuss where the gaps in care were and how to eliminate them. Then, a smaller heart failure team worked to design a transition clinic that would support, educate and provide resources for heart failure patients. The purpose was to close a potential gap in care where patients were discharged from the hospital with no specific resources on how to manage their complex disease. 

Beginning with a pilot
To test their design, the heart failure care stakeholders began with a pilot project that could later be scaled up to the entire CHS organization. In the pilot program, a nurse navigator — who Dr. Gulati calls the "quarterback" of the team — would visit all inpatients who had a primary diagnosis of congestive heart failure. This evaluation went beyond clinical factors to include an assessment of the patient's, as well as his or her family's, needs. The nurse navigator also gave patients initial education on the complexities of their disease.

Within three days after hospital discharge, patients who voluntarily entered the Heart Success program met with advanced care practitioners and nurses trained in heart failure to receive more in-depth education on how to better manage their disease. These practitioners, along with a pharmacist, dietician and social worker, educated patients about medication, diet and other behavior, and helped patients identify resources, such as cardiac rehab and home nursing, and other needs based on the evaluation sent from the nurse navigator. In addition to helping patients access the care they need, this process helps the practitioners identify which patients are at higher risk for readmission and who may need more monitoring.

In the first week of the pilot, this first educational meeting took an average of two-and-a-half hours. "We felt that period of time was a little overwhelming," Dr. Gulati says. "[Patients] are just out of the hospital with a chronic disease, and they have a two-and-a-half-hour lecture. That can be difficult." The team quickly changed the structure of the first educational meetings, which shortened the time to one hour.

Expanding the pilot to the system

To make the educational component more manageable, the Heart Success team schedules each patient for up to four, 30-minute in-clinic meetings over the next four weeks after the initial meeting. The care team will also call patients throughout that time period to follow up on what was discussed in the previous meeting and to answer questions about diet or medicine the patients may have. 

While Heart Success is part of Sanger Heart & Vascular Institute, it focuses on the short transition period between hospital and home, rehabilitation or a skilled nursing facility, whereas the Institute focuses on long-term care. Separating transition services from chronic care services allows CHS to devote the appropriate resources to each patient depending on the acuity of their condition.

Multiple points of entry
One of the biggest challenges of expanding Heart Success system-wide was coordinating care for patients entering through multiple entry points, such as the emergency department, a primary care physician or a specialist. Each hospital within the system had to evaluate its own patient population and needs to tailor the program to the institution, Dr. Gulati says. In order for programs to succeed in other hospitals, each program has to be tailored to the primary, tertiary and quaternary environment of each facility.

To reach chronic heart failure patients who are not inpatients at CHS and receive the majority of their care from their primary care physician or cardiologist, the Heart Success team communicates with these physicians to make them aware of the transition program. The Heart Success team developed and distributed algorithms and protocols to primary care physicians and cardiologists to notify them of the resources for their chronic heart failure patients.

Provider engagement
The value of Heart Success lies not only in helping patients connect to needed resources, but also in encouraging provider and patient engagement in the patient's care. "What really developed here, and what you need to be successful in the management of heart failure, is a model where providers are engaged," Dr. Gulati says.

The Heart Success program fosters provider engagement because it enables physicians to care for patients beyond discharge. By focusing on not only medical needs, but also logistical needs such as transportation, health insurance and personal support, the transition clinic forces providers to take a holistic, rather than a silo, narrow view of the patient.

Educating heart failure patients and helping them access post-discharge services also encourages patient engagement, because patients have a better understanding of what resources they need to stay healthy and how they can access those resources. "It's transforming patients from having things done to them to becoming active managers of the disease. It's empowering them to be successful in managing their disease," Dr. Gulati says. Patient engagement can increase patient satisfaction because patients feel more in control, and can improve long-term outcomes.

What's in a name? Empowerment
The name of the transition program itself also promotes patient engagement and empowerment, according to Dr. Gulati. He says that while it may seem "corny," it was chosen very deliberately. "'Failure' is not a good term for patients having a good outlook. There's a negative connotation even though everybody uses [the term 'heart failure']. We wanted to empower patients from a psychological standpoint." Focusing on heart success instead of heart failure may help patients think more positively about their condition and their ability to manage the disease.

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